What is the difference between FRAX and FRAXplus?

Osteoporosis affects millions globally, and for over a decade, the FRAX tool has been the standard for calculating fracture risk. However, as medicine advances, so do our assessment tools. To provide a more refined evaluation, a new platform called FRAXplus was developed, and understanding what is the difference between FRAX and FRAXplus? is crucial for accurate senior care.

Quick Summary

The main difference is that FRAXplus is an advanced platform that applies specific adjustments to the standard FRAX calculation, allowing for a more nuanced and accurate assessment of an individual's fracture risk based on granular clinical data not included in the original FRAX model. FRAX provides a baseline 10-year probability, while FRAXplus incorporates details like recent fracture timing, medication dose, and fall history for a more precise outcome.

Key Points

• Core vs. Enhanced: FRAX is the standard, free calculator for baseline fracture probability, while FRAXplus is a subscription-based platform that refines FRAX scores with additional patient data.

• Data Granularity: FRAX uses binary (yes/no) inputs for most risk factors; FRAXplus allows for quantitative adjustments for factors like glucocorticoid dose, recent fracture timing, and number of falls.

• Personalized Assessment: FRAXplus enables more personalized and accurate risk assessment by including nuanced factors like Trabecular Bone Score (TBS) and duration of Type 2 diabetes.

• Clinical Impact: The adjustments in FRAXplus can reclassify patients' fracture risk, helping clinicians to better identify those who are high-risk and need treatment.

• Validation and Cost: FRAX is extensively validated and free, whereas FRAXplus uses empirically-derived adjustments that require a paid subscription and are based on separate validation studies.

Understanding the Foundational FRAX Tool

First, let's look at FRAX. The Fracture Risk Assessment Tool, or FRAX, was launched in 2008 and is a free, accessible way to estimate a person's 10-year probability of a major osteoporotic fracture or a hip fracture. It is used to help identify patients who might benefit from intervention, particularly those with osteopenia. FRAX calculates risk using easily available clinical risk factors, with or without femoral neck BMD.

Key FRAX input variables include:

• Age, sex, height, weight (or BMI)
• Previous fragility fracture
• Parental history of hip fracture
• Current smoking status
• Long-term oral glucocorticoid use
• Rheumatoid arthritis
• Excessive alcohol consumption
• Other causes of secondary osteoporosis
• Femoral neck Bone Mineral Density (BMD) T-score, if available

Limitations of the Standard FRAX Model

The standard FRAX tool has limitations as it primarily uses binary (yes/no) inputs, not accounting for dose-response or the recency of risk factors. This means it doesn't distinguish between single vs. multiple fractures or recent vs. past fractures, potentially underestimating risk. It also standardizes certain factors like glucocorticoid use.

The Evolution to FRAXplus

FRAXplus is a web-based platform designed to refine the core FRAX algorithm with quantitative adjustments, addressing the standard model's limitations. It allows clinicians to use more granular patient data for a more precise risk estimate. While FRAX is free, FRAXplus's advanced features require a subscription.

What FRAXplus adjusts for:

• Prior fracture details: Adjusts for the recency and site of previous fractures.
• Higher dose glucocorticoids: Provides a more accurate adjustment for higher doses of oral glucocorticoids.
• Trabecular Bone Score (TBS): Includes a validated adjustment for TBS, which assesses bone microarchitecture.
• Falls history: Adjusts risk based on the number of falls in the previous year.
• Duration of Type 2 diabetes: Accounts for increased risk with longer duration of T2DM.
• Lumbar Spine BMD: Allows for adjustments based on lumbar spine and femoral neck BMD T-score discordances.
• Hip Axis Length (HAL): Provides an adjustment for HAL, which can influence hip fracture risk.

A side-by-side comparison: FRAX vs FRAXplus

Feature	FRAX (Standard)	FRAXplus (Advanced)
Purpose	Estimate 10-year fracture probability using standard clinical risk factors and BMD.	Refine FRAX probabilities using additional, granular patient data.
Variables	Binary (yes/no) inputs for most clinical risk factors. Fixed values for BMD/age.	Quantitative and more detailed inputs for risk factors.
Recency of Fracture	Not considered. Assumes constant risk.	Incorporates recent fracture timing and site to adjust risk upward.
Glucocorticoid Dose	Binary input (yes/no), assuming a moderate dose.	Adjusts risk based on empirical data for higher oral glucocorticoid doses.
Falls History	Assumes average fall risk.	Adjusts risk based on number of falls in the past year.
Other Factors	Limited secondary osteoporosis factors (binary).	Includes adjustments for TBS, duration of T2DM, BMD discordance, and HAL.
Target Audience	General practitioners and clinicians for routine screening.	Specialists, endocrinologists, and clinicians needing a more detailed assessment.
Cost	Freely available online and in many guidelines.	Subscription-based for access to the adjustment features.
Validation	Extensively validated in large, diverse international cohorts.	Adjustments are based on empirical data but validated separately from the core FRAX model.

Clinical Implications of Using FRAXplus

Using FRAXplus can lead to significant clinical benefits by reclassifying patients into higher-risk categories, enabling targeted preventative treatment. For example, a recent fracture could significantly increase a patient's risk score with FRAXplus, shifting them towards a treatment recommendation. This improved stratification allows for more personalized treatment decisions and potentially reduced fracture incidence. More detailed information on fracture risk assessment can be found on the FRAXplus® Official Website.

Conclusion: Choosing the Right Tool for the Job

FRAX remains a robust and widely used tool for initial screening, providing a reliable baseline risk calculation. It is simple to use and integrated into many guidelines. FRAXplus, however, offers a more powerful, refined analysis for patients whose risk factors require a more nuanced approach than the standard FRAX model provides. By incorporating additional, validated factors and dose-response relationships, FRAXplus allows for more accurate risk stratification and informed treatment decisions, especially in complex cases. This highlights a move towards personalized medicine in senior care for better fracture prevention outcomes.

Frequently Asked Questions

Who should use FRAX, and who should use FRAXplus?

FRAX is ideal for initial, routine fracture risk screening in primary care settings. FRAXplus is more suited for specialists or situations where a patient presents with complex risk factors that require a more granular and refined assessment than the standard FRAX tool can provide.

Does FRAXplus replace the original FRAX tool?

No, FRAXplus does not replace FRAX. It is a supplementary tool that uses the FRAX algorithm as its foundation. Think of FRAX as the baseline calculation, and FRAXplus as a set of add-ons that enhance the precision of that baseline result.

What kind of additional data does FRAXplus use?

FRAXplus uses detailed data such as the specific timing and site of a previous fracture, the exact dose of glucocorticoid medication, the number of falls a patient has had in the last year, and objective measures like the Trabecular Bone Score (TBS) and Hip Axis Length (HAL).

Why is the timing of a previous fracture important in FRAXplus?

The risk of a recurrent fracture is highest in the period immediately following an initial fracture. The FRAXplus tool accounts for this by applying a specific multiplier that increases the patient's risk probability based on how recently their last osteoporotic fracture occurred.

Is the Trabecular Bone Score (TBS) necessary for using FRAXplus?

TBS is not required to use FRAXplus, but it is one of the available adjustments. If a patient has a TBS measurement from their DXA scan, entering it into FRAXplus can provide a more accurate risk prediction by factoring in bone microarchitecture, which is independent of BMD.

Can I use FRAXplus to monitor my progress on osteoporosis treatment?

No, neither FRAX nor FRAXplus are intended for monitoring treatment effectiveness. These tools are designed for initial risk assessment in untreated individuals to help guide treatment decisions. They should not be used to track changes in risk while a patient is on therapy.

Is FRAX still considered a valid tool for fracture risk assessment?

Yes, FRAX remains a valid and widely-used tool. It is extensively validated and incorporated into numerous clinical guidelines worldwide. It provides a reliable starting point, especially when more detailed data is not available, but its limitations should be considered in complex cases.